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Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. | PSNet

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October 06, 2021 - Commentary Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. Citation Text: Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/ao…

An IDEA: safety training to improve critical thinking by individuals and teams. | PSNet

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May 25, 2016 - Commentary An IDEA: safety training to improve critical thinking by individuals and teams. Citation Text: Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/106286061882068…

Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. | PSNet

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January 02, 2017 - Study Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Citation Text: Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16. Copy Citation Format: …

Use of a novel, modified fishbone diagram to analyze diagnostic errors. | PSNet

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February 13, 2019 - Commentary Use of a novel, modified fishbone diagram to analyze diagnostic errors. Citation Text: Reilly JB, Myers JS, Salvador D, et al. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171. doi:10.1515/dx-2013-0040. Copy Citation…

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse. | PSNet

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November 11, 2020 - Commentary Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse. Citation Text: Liese KL, Davis-Floyd R, Stewart K, et al. Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, an…

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. | PSNet

psnet.ahrq.gov/issue/association-between-implementing-comprehensive-learning-collaborative-strategies-statewide

September 02, 2020 - Study Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. Citation Text: Yuce TK, Yang AD, Johnson JK, et al. Association between implementing comprehensive learning collaborative strategies…

Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. | PSNet

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May 07, 2014 - Book/Report Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. Citation Text: Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Ag…

Accuracy of radiographic readings in the emergency department. | PSNet

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November 18, 2016 - Study Accuracy of radiographic readings in the emergency department. Citation Text: Petinaux B, Bhat R, Boniface K, et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med. 2011;29(1):18-25. doi:10.1016/j.ajem.2009.07.011. Copy Citation Format: …

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. | PSNet

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February 17, 2011 - Commentary Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. Citation Text: Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736. …

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. | PSNet

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July 29, 2020 - Study Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. Citation Text: Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. | PSNet

psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare

January 26, 2022 - Commentary To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. Citation Text: Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2…

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. | PSNet

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October 19, 2022 - Commentary Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Citation Text: Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…

Improving communication in the ICU using daily goals. | PSNet

psnet.ahrq.gov/issue/improving-communication-icu-using-daily-goals

December 19, 2018 - Study Improving communication in the ICU using daily goals. Citation Text: Pronovost P, Berenholtz SM, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML End…

Opioid abuse in chronic pain—misconceptions and mitigation strategies. | PSNet

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November 18, 2016 - Review Opioid abuse in chronic pain—misconceptions and mitigation strategies. Citation Text: Volkow ND, McLellan T. Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. New Engl J Med. 2016;374(13):1253-1263. doi:10.1056/NEJMra1507771. Copy Citation Format: …

National Action Plan for Adverse Drug Event Prevention. | PSNet

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October 16, 2013 - Book/Report National Action Plan for Adverse Drug Event Prevention. Citation Text: National Action Plan for Adverse Drug Event Prevention. Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014. Copy Cita…

The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. | PSNet

psnet.ahrq.gov/issue/impact-drug-shortages-patients-cardiovascular-disease-causes-consequences-and-call-action

October 10, 2012 - Review The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. Citation Text: Reed BN, Fox ER, Konig M, et al. The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. Am He…

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. | PSNet

psnet.ahrq.gov/issue/context-sensitive-decision-support-infobuttons-electronic-health-records-systematic-review

August 23, 2023 - Review Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. Citation Text: Cook DA, Teixeira MT, Heale BS, et al. Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. J Am Med Inform Assoc. 2017…

Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes. | PSNet

psnet.ahrq.gov/issue/association-between-centers-medicare-and-medicaid-services-hospital-star-rating-and-patient

December 18, 2018 - Study Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes. Citation Text: Wang DE, Tsugawa Y, Figueroa JF, et al. Association Between the Centers for Medicare and Medicaid Services Hospital Star Rating and Patient Outcomes. JAMA In…

The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. | PSNet

psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools

September 23, 2020 - Commentary The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. Citation Text: Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…

Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences. | PSNet

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August 28, 2024 - Commentary Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences. Citation Text: Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and …

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